<%@ page contentType="text/html;charset=UTF-8" language="java" %>
<%@ page language="java" import="java.util.*" pageEncoding="UTF-8"%>
<%@taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core" %>
<%@ taglib uri="http://java.sun.com/jsp/jstl/fmt" prefix="fmt" %>
<!DOCTYPE html>
<html lang="zh-CN">
<head>
    <jsp:include page="../head.jsp" flush="true">
        <jsp:param name="title" value="后台管理系统 - 用户管理"/>
    </jsp:include>
    <style>
        td{width:100px;heitht:20px;}
        table{text-align:center;}
        p{width:1000px;}
        input{width:100px;height:20px;}
    </style>
    <script type="text/javascript">
        function checkForm() {
            if (window.confirm("确定提交表格并进入下一表格吗？\r\注意：表格不可重复填写！")) {
                return true;
            }
            return false;
        }
    </script>
</head>
<body  align="center">
<!-- 头导航 -->
<jsp:include page="../navbar.jsp"/>

<form action="${domain}/admin/fourth/b" method="post"  onsubmit="return checkForm()">
    <div align="center" width="1000px">
        <td><input name="oName" type="hidden" value="${oName}"></td>

        <h4>表2 门诊服务费用调查表</h4>
      <p align="left">
            注：</br>
            填表说明：
    如果本诊所2016年门诊记录和处方保存完好，则在2016年的四个季度中分别随机选择一个星期，调阅门诊记录和处方，填写患者年龄、性别、类疾病诊断、收费及医疗保险补偿信息。如果2016年门诊记录和处方无法调出，则抽取调查前一个月的门诊记录和处方进行汇总。对于门诊量较小的诊所，所抽取的四周门诊量小于150条，则继续增加其他时间内的门诊患者信息，保证门诊患者记录条数不小于150条。
        </p>

        <table border="1" cellspacing="0" cellpadding="0">
            <tr>
                <td>序号</td>
                <td >年龄</td>
                <td>性别</td>
                <td>主要诊断</td>
                <td >门诊收费（元）</td>
                <td>其中:药品收入（元）</td>
                <td>保险支付总额（元）</td>
            </tr>
            <c:forEach var="s"  begin="0" end="39">
                <tr>
                    <td>${s+1}</td>
                    <td ><input name=fourthB_p[${s*6+0}]></td>
                    <td><input name=fourthB_p[${s*6+1}]></td>
                    <td><input name=fourthB_p[${s*6+2}]></td>
                    <td><input name=fourthB_p[${s*6+3}] type="number" step="0.01"></td>
                    <td><input name=fourthB_p[${s*6+4}] type="number" step="0.01"></td>
                    <td><input name=fourthB_p[${s*6+5}] type="number" step="0.01"></td>
                </tr>
            </c:forEach>
            <c:forEach var="s"  begin="0" end="39">
            <tr>
                <td>${s+41}</td>
                <td ><input name=fourthB_pp[${s*6+0}]></td>
                <td><input name=fourthB_pp[${s*6+1}]></td>
                <td><input name=fourthB_pp[${s*6+2}]></td>
                <td><input name=fourthB_pp[${s*6+3}] type="number" step="0.01"></td>
                <td><input name=fourthB_pp[${s*6+4}] type="number" step="0.01"></td>
                <td><input name=fourthB_pp[${s*6+5}] type="number" step="0.01"></td>
            </tr>
        </c:forEach>
            <c:forEach var="s"  begin="0" end="39">
                <tr>
                    <td>${s+81}</td>
                    <td ><input name=fourthB_ppp[${s*6+0}]></td>
                    <td><input name=fourthB_ppp[${s*6+1}]></td>
                    <td><input name=fourthB_ppp[${s*6+2}]></td>
                    <td><input name=fourthB_ppp[${s*6+3}] type="number" step="0.01"></td>
                    <td><input name=fourthB_ppp[${s*6+4}] type="number" step="0.01"></td>
                    <td><input name=fourthB_ppp[${s*6+5}] type="number" step="0.01"></td>
                </tr>
            </c:forEach>
            <c:forEach var="s"  begin="0" end="29">
                <tr>
                    <td>${s+121}</td>
                    <td ><input name=fourthB_pppp[${s*6+0}]></td>
                    <td><input name=fourthB_pppp[${s*6+1}]></td>
                    <td><input name=fourthB_pppp[${s*6+2}]></td>
                    <td><input name=fourthB_pppp[${s*6+3}] type="number" step="0.01"></td>
                    <td><input name=fourthB_pppp[${s*6+4}] type="number" step="0.01"></td>
                    <td><input name=fourthB_pppp[${s*6+5}] type="number" step="0.01"></td>
                </tr>
            </c:forEach>
        </table>
      <button type="submit" ><b>提交并进入下一表格</b></button>



    </div>

</form>
</body>
</html>